The current significance of the FOUR score: A systematic review and critical analysis of the literature

Comparison of Glasgow Coma Scale and Full Outline of UnResponsiveness score to assess the level of consciousness in patients admitted to intensive care units and emergency departments: A quantitative systematic review

OBJECTIVES

We aimed to investigate the reliability and validity of the Glasgow Coma Scale (GCS) and the Full Outline of UnResponsiveness (FOUR) score used by nurses and physicians to assess the level of consciousness in patients admitted to intensive care units (ICUs) and emergency departments (EDs).

REVIEW METHOD USED

This systematic review was guided by the Cochrane Handbook for Systematic Reviews of Interventions and followed the reporting standards of the Preferred Reporting Items for Systematic Review and Meta-Analysis Statement.

DATA SOURCES

A systematic search was conducted using the following databases: CINAHL, MEDLINE, and EMBASE.

REVIEW METHODS

All authors performed the study selection process, data collection, and assessment of quality. The following psychometric properties were addressed: inter-rater reliability, internal consistency, and construct validity.

RESULTS

Six articles were included. The GCS and the FOUR scores demonstrated excellent reliability and very strong validity when used by nurses and physicians to assess the level of consciousness in patients admitted to the ICU and ED. The FOUR score demonstrated slightly higher overall reliability and validity than the GCS.

CONCLUSION

This systematic review indicates that the FOUR score is especially suitable for assessing the level of consciousness in patients admitted to the ICU and ED. The FOUR score demonstrated higher reliability and validity than the GCS, making it a promising alternative assessment scale, despite the GCS's longstanding use in clinical practice.

Complex auditory regularity processing across levels of consciousness in coma: Stage 1 Registered Report

A key question for the scientific study of consciousness is whether it is possible to identify specific features in brain activity that are uniquely linked to conscious experience. This question has important implications for the development of markers to detect covert consciousness in unresponsive patients. In this regard, many studies have focused on investigating the neural response to complex auditory regularities. One noteworthy example is the local global paradigm, which allows for the investigation of auditory regularity encoding at the 'global' level, based on the repetition of groups of sounds. The inference of global regularities is thought to depend on conscious access to such complex auditory stimuli as mostly shown in chronic stages of disorders of consciousness patients. However, whether global regularity encoding can identify covert consciousness along the consciousness spectrum including earlier stages of these disorders remains controversial. Here, we aim to fill this gap by investigating whether the inference of global auditory regularities can occur in acute coma, in the absence of consciousness, and how this may be modulated by the severity of the patients' clinical condition and consciousness level measured using the Full Outline of UnResponsiveness (FOUR) score. We will acquire 63-channel continuous electroencephalography to measure the neural response to global auditory regularity in comatose patients (N = 30) during the first day after cardiac arrest, when patients are unconscious, sedated and under normothermia, and during the second day (with reduced or absent sedation and body temperature control). We hypothesize that global regularity encoding will persist in the absence of consciousness independent of patient outcome, observed as above chance decoding of the neural response to global regularities using multivariate decoding analyses. We further hypothesize that decoding performance will positively correlate with the FOUR score, which indexes consciousness level, and typically improves between the first and second day after coma onset following cardiac arrest in patients with favourable outcome. In an exploratory analysis, we will also evaluate whether global regularity encoding may be influenced by the patients' clinical management, specifically sedation, also shown to affect global deviance detection. Our results will shed light on the neurophysiological correlates of complex auditory regularity processing in unconscious patients and on the link to residual levels of consciousness during the underexplored state of coma upon the first days after cardiac arrest.

The Predictive Validity of the Full Outline of UnResponsiveness Score Compared to the Glasgow Coma Scale in the Intensive Care Unit: A Systematic Review

The Full Outline of UnResponsiveness (FOUR) score was developed to overcome the limitations of the Glasgow Coma Scale (GCS) when assessing individuals with impaired consciousness. We sought to review the evidence regarding the predictive validity of the GCS and FOUR score in intensive care unit (ICU) settings. This review was prospectively registered in PROSPERO (CRD42023420528). Systematic searches of CINAHL, MEDLINE, and Embase were undertaken. Prospective observational studies were included if both GCS and FOUR score were assessed in adults during ICU admission and if mortality and/or validated functional outcome measure scores were collected. Studies were excluded if they exclusively investigated patients with traumatic brain injury. Screening, data extraction, and quality assessment using the Quality in Prognosis Studies tool were conducted by two reviewers. Twenty studies of poor to moderate quality were included. Many studies only included patients with neurological illness and excluded sedated patients, despite high proportions of intubated patients. The FOUR score achieved higher area under the receiver operating characteristic curve values for mortality prediction compared with the GCS, and the FOUR score achieved significantly higher area under the receiver operating characteristic curve values for predictions of ICU mortality. Both coma scales showed similar accuracy in predicting "unfavorable" functional outcome. The FOUR score appeared to be more responsive than the GCS in the ICU, as most patients with a GCS score of 3 obtained FOUR scores between 1 and 8 due to preserved brainstem function. The FOUR score may be superior to the GCS for predicting mortality in ICU settings. Further adequately powered studies with clear, reliable methods for assessment of index and outcome scores are required to clarify the predictive performance of both coma scales in ICUs. Inclusion of sedated patients may improve generalizability of findings in general ICU populations.

The Glasgow Coma Scale and Full Outline of Unresponsiveness score evaluation to predict patient outcomes with neurological illnesses in intensive care units in West Bank: a prospective cross-sectional study

BACKGROUND

Determining the clinical neurological state of the patient is essential for making decisions and forecasting results. The Glasgow Coma Scale and the Full Outline of Unresponsiveness (FOUR) Scale are commonly used tools for measuring behavioral consciousness. This study aims to compare scales among patients with neurological disorders in intensive care units (ICUs) in the West Bank.

METHODS

A prospective cross-sectional design was employed. All patients admitted to ICUs who met inclusion criteria were involved in this study. Data were collected from from An-Najah National University, Al-Watani, and Rafedia Hospital. Both tools were used to collect data.

RESULTS

A total of 84 patients were assessed, 69.0% of the patients were male, and the average length of stay was 6.4 days. The mean score on the Glasgow Coma scale was 11.2 on admission 11.6 after 48 hours, and 12.2 on discharge. The mean FOUR Scale score was 12.2 on admission, 12.4 after 48 hours, and 12.5 at discharge.

CONCLUSIONS

This study indicates that both the Glasgow Coma Scale and the FOUR scale are effective in predicting outcomes for neurologically deteriorated critically ill patients. However, the FOUR scale proved to be more reliable when assessing outcomes in ICU patients.

Development of a Novel Neurological Score Combining GCS and FOUR Scales for Assessment of Neurosurgical Patients with Traumatic Brain Injury: GCS-FOUR Scale

BACKGROUND

Consciousness assessment is crucial for patients with traumatic brain injury. In this study, we developed a novel scoring system combining the Glasgow coma scale (GCS) and the full outline of unresponsiveness (FOUR) and evaluated its association with the intensive care unit (ICU) length of stay, mortality, and functional outcome.

METHODS

We retrospectively analyzed the data from patients with traumatic brain injury admitted to the neurosurgical ICU of our institution during a 2-year period. The eye and motor components of the GCS and the brainstem reflex component of the FOUR were used to compute the GCS-FOUR. We performed statistical analysis to demonstrate the association between the GCS, FOUR, and GCS-FOUR and the ICU length of stay, mortality, the development of a persistent vegetative state, and desirable recovery.

RESULTS

A total of 140 patients were included. The mean age was 30.6 years, and 89.3% were male. All 3 scores were associated with the ICU length of stay, mortality, a persistent vegetative state, and good recovery. In terms of predicting mortality, the GCS score exhibited a slight superiority compared with the other indexes, and the GCS-FOUR score showed a slight superiority over the other indexes in predicting for good recovery.

CONCLUSIONS

The GCS-FOUR is a novel scoring system comparable to the GCS and FOUR regarding its association with functional status after injury, ICU length of stay, and mortality. The GCS-FOUR score provides greater neurological detail than the GCS due to the inclusion of brainstem reflexes, in addition to using the experience of healthcare providers with the GCS score compared with the FOUR in most settings.

Assessing consciousness and cognition in disorders of consciousness

Detecting willful cognition in these patients is known to be challenging due to the patients' motor disabilities and high vigilance fluctuations but also due to the lack of expertise and use of adequate tools to assess these patients in specific settings. This review will discuss the main disorders of consciousness after severe brain injury, how to assess consciousness and cognition in these patients, as well as the challenges and tools available to overcome these challenges and reach an accurate diagnosis.

Effect of an educational program on pediatric nurses' knowledge, practice, and self-confidence about level of consciousness scales

BACKGROUND

Nurses of pediatric acute critical care units routinely assess the Level of Consciousness (LOC). The precise, exact, and restriction-free evaluation tool aids pediatric nurses in LOC assessment and clinical decision-making. This study aimed to examine the effect of an educational program on pediatric nurses' knowledge, practice, and self-confidence about level of consciousness scales.

METHODS

This pretest-post, single-group, quasi-experimental, double-site study included 49 pediatric nurses. The Glasgow Coma Scale (GCS)/Pediatric Glasgow Coma Scale (PGCS) and Pediatric Full Outline of UnResponsiveness Score Scale (PFSS) knowledge questionnaire and pediatric nurse practice checklist were developed and adopted. Self-reflection confidence statements were rated 1-5 (not confident-confident).

RESULTS

The results of the study indicate that there were significant increases in knowledge, practice, and self-confidence after the intervention. The paired samples tests revealed that knowledge scores significantly increased from the pretest to the posttest for both GCS/PGCS (pretest mean:7.91, posttest mean:9.95) and PFSS (pretest mean:2.1, posttest mean:6.79). Practice scores also showed significant improvement for both GCS/PGCS (pretest mean: 4.12, post-test mean: 6.22) and PFSS (pretest mean: 2.46, post-test mean: 5.79). Furthermore, self-confidence significantly improved for GCS/PGCS (pretest mean:16.08, posttest mean:18.79) and PFSS (pretest mean:10.32, posttest mean:17.81). The statistical analyses supported the significance of these improvements (p < 0.001 for all except self-confidence in GCS/PGCS with p < 0.005).

CONCLUSION

The educational program improved pediatric nurses' GCS/PGCS and PFSS knowledge, practice, and self-confidence.

IMPLICATIONS TO PRACTICE

Effective teaching of pediatric nurses is required to address gaps in care practices and improve the use of the Consciousness Level Assessment Scales.

Comparison of Glasgow Coma Scale and Full Outline of UnResponsiveness score for prediction of in-hospital mortality in traumatic brain injury patients: a systematic review and meta-analysis

BACKGROUND

Currently, Glasgow Coma Scale (GCS) is used to assess patients' level of consciousness. Although this tool is highly popular in clinical settings, it has various limitations that reduce its applicability in certain situations. This had led researchers to look for alternative scoring systems. This study aims to compare the value of GCS and Full Outline of UnResponsiveness (FOUR) score for prediction of mortality in traumatic brain injury (TBI) patients through a systematic review and meta-analysis.

METHOD

Online databases of Medline, Embase, Scopus, and Web of Science were searched until the end of July 2022 for studies that had compared GCS and FOUR score in TBI patients. Interested outcomes were mortality and unfavorable outcome (mortality + disability). Findings are reported as area under the curve (AUC) sensitivity, specificity, and diagnostic odds ratio.

RESULTS

20 articles (comprised of 2083 patients) were included in this study. AUC of GCS and FOUR score for prediction of in-hospital mortality after TBI was 0.92 (95% CI 0.80-0.91) and 0.91 (95% CI 0.88-0.93) respectively. The diagnostic odds ratio of the two scores for prediction of in-hospital mortality after TBI was 44.51 (95% CI 23.58-84.03) for GCS and 45.16 (95% CI 24.25-84.09) for FOUR score. As for prediction of unfavorable outcome after TBI, AUC of GCS and FOUR score were 0.95 (95% CI 0.93 to 0.97) and 0.93 (95% CI 0.91-0.95), respectively. The diagnostic odds ratios for prediction of unfavorable outcome after TBI were 66.31 (95% CI 35.05-125.45) for GCS and 45.39 (95% CI 23.09-89.23) for FOUR score.

CONCLUSION

Moderate level of evidence showed that the value of GCS and FOUR score in the prediction of in-hospital mortality and unfavorable outcome is comparable. The similar performance of these scores in assessment of TBI patients gives the medical staff the option to use either one of them according to the situation at hand.

A functional near-infrared spectroscopy study on hemodynamic changes of patients with prolonged disorders of consciousness responding to different auditory stimuli

Treating prolonged disorders of consciousness (pDoC) is challenging. Thus, accurate assessment of residual consciousness in patients with pDoC is important for the management and recovery of patients. Functional near-infrared spectroscopy (fNIRS) can be used to detect brain activity through changes of oxygenated hemoglobin/deoxygenated hemoglobin (HbO/HbR) concentrations changes and has recently gained increasing attention for its potential applications in assessing residual consciousness. However, the number of fNIRS studies assessing residual awareness in patients with pDoC is still limited. In this study, fNIRS was used to evaluate the brain function in 18 patients with pDoC, including 14 vegetative states (VS) and 4 minimally conscious states (MCS), and 15 healthy controls (HC). All participants accepted two types of external stimuli, i.e., active stimulation (motor imagery, MI) and passive stimulation (subject's own name, SON). The results showed that the mean concentrations of HbO/HbR in the prefrontal cortex of the HC during the passive stimulation were significantly lower than those of the active stimulation, and the fitting slope was high. However, the hemodynamic responses of the patients with pDoC were opposite to those of the HC. Additionally, the mean concentrations of HbO/HbR increased as the level of consciousness decreased during passive stimulation. Our findings suggest that the residual level of consciousness in pDoC patients can be assessed by measuring brain responses to different stimulations using fNIRS. The present study further demonstrates the feasibility and reliability of fNIRS in assessing residual consciousness in patients with pDoC, providing a basis for its expanded clinical application.

Growth Hormone Deficiency following Traumatic Brain Injury in Pediatric and Adolescent Patients: Presentation, Treatment, and Challenges of Transitioning from Pediatric to Adult Services

Traumatic brain injury (TBI) is increasingly recognized, with an incidence of approximately 110 per 100,000 in pediatric populations and 618 per 100,000 in adolescent and adult populations. TBI often leads to cognitive, behavioral, and physical consequences, including endocrinopathies. Deficiencies in anterior pituitary hormones (e.g., adrenocorticotropic hormone, thyroid-stimulating hormone, gonadotropins, and growth hormone [GH]) can negatively impact health outcomes and quality of life post-TBI. This review focuses on GH deficiency (GHD), the most common post-TBI pituitary hormone deficiency. GHD is associated with abnormal body composition, lipid metabolism, bone mineral density, executive brain functions, behavior, and height outcomes in pediatric, adolescent, and transition-age patients. Despite its relatively frequent occurrence, post-TBI GHD has not been well studied in these patients; hence, diagnostic and treatment recommendations are limited. Here, we examine the occurrence and diagnosis of TBI, retrospectively analyze post-TBI hypopituitarism and GHD prevalence rates in pediatric and adolescent patients, and discuss appropriate GHD testing strategies and GH dosage recommendations for these patients. We place particular emphasis on the ways in which testing and dosage recommendations may change during the transition phase. We conclude with a review of the challenges faced by transition-age patients and how these may be addressed to improve access to adequate healthcare. Little information is currently available to help guide patients with TBI and GHD through the transition phase and there is a risk of interrupted care; therefore, a strength of this review is its emphasis on this critical period in a patient's healthcare journey.

Can Respiration Complexity Help the Diagnosis of Disorders of Consciousness in Rehabilitation?

BACKGROUND

Autonomic Nervous System (ANS) activity, as cardiac, respiratory and electrodermal activity, has been shown to provide specific information on different consciousness states. Respiration rates (RRs) are considered indicators of ANS activity and breathing patterns are currently already included in the evaluation of patients in critical care.

OBJECTIVE

The aim of this work was to derive a proxy of autonomic functions via the RR variability and compare its diagnostic capability with known neurophysiological biomarkers of consciousness.

METHODS

In a cohort of sub-acute patients with brain injury during post-acute rehabilitation, polygraphy (ECG, EEG) recordings were collected. The EEG was labeled via descriptors based on American Clinical Neurophysiology Society terminology and the respiration variability was extracted by computing the Approximate Entropy (ApEN) of the ECG-derived respiration signal. Competing logistic regressions were applied to evaluate the improvement in model performances introduced by the RR ApEN.

RESULTS

Higher RR complexity was significantly associated with higher consciousness levels and improved diagnostic models' performances in contrast to the ones built with only electroencephalographic descriptors.

CONCLUSIONS

Adding a quantitative, instrumentally based complexity measure of RR variability to multimodal consciousness assessment protocols may improve diagnostic accuracy based only on electroencephalographic descriptors. Overall, this study promotes the integration of biomarkers derived from the central and the autonomous nervous system for the most comprehensive diagnosis of consciousness in a rehabilitation setting.

Development and validation of a novel poisoning agitation-sedation score for predicting the need for endotracheal intubation and mechanical ventilation in acutely poisoned patients with disturbed consciousness

BACKGROUND

Accurate assessment of disturbed consciousness level (DCL) is crucial for predicting acutely poisoned patients' outcomes.

AIM

Development of a novel Poisoning Agitation-Sedation Score (PASS) to predict the need for endotracheal intubation (ETI) and mechanical ventilation (MV) in acutely poisoned patients with DCL. Validation of the proposed score on a new set of acutely poisoned patients with DCL.

METHODS

This study was conducted on 187 acutely poisoned patients with DCL admitted to hospital from June 2020 to November 2021 (Derivation cohort). Patients' demographics, toxicological data, neurological examination, calculation of the Glasgow Coma Scale (GCS), Full Outline of Unresponsiveness (FOUR) score, Richmond Agitation-Sedation Scale (RASS), and outcomes were gathered for developing a new score. The proposed score was externally validated on 100 acutely poisoned patients with DCL (Validation cohort).

RESULTS

The PASS assessing sedation consists of FOUR (reflexes and respiration) and GCS (motor) and provides a significantly excellent predictive power (AUC = 0.975) at a cutoff ≤9 with 100% sensitivity and 92.11% specificity for predicting the need for ETI and MV in sedated patients. Additionally, adding RASS (agitation) to the previous model exhibits significantly good predictive power (AUC = 0.893), 90.32% sensitivity, and 73.68% specificity at a cutoff ≤14 for predicting the need for ETI and MV in disturbed consciousness patients with agitation.

CONCLUSION

The proposed PASS could be an excellent, valid and feasible tool to predict the need for ETI and MV in acutely poisoned disturbed consciousness patients with or without agitation.

Comparison of the prognostic value of coma scales among health-care professionals: a prospective observational study

OBJECTIVE

To assess the predictive value of the Full Outline of Unresponsiveness (FOUR) Score and the Glasgow Coma Scale (GCS), investigating whether they are comparable in predicting short- and long-term functional outcome and if their predictive ability remains unaffected by the raters' background and experience.

METHODS

Patients treated in the Neurosurgery Department and the Intensive Care Unit in need for consciousness monitoring were assessed between October 1st, 2018, and December 31st, 2020, by four raters (two consultants, a resident and a nurse) using the two scales on admission and at discharge. Outcome was recorded at discharge and at 6 months. Areas under the receiver operating characteristic curve (AUCs) were calculated for the prediction of mortality and poor outcome, and the identification of coma.

RESULTS

Eighty-six patients were included. AUCs values were > 0.860 for all outcomes and raters. No significant differences were noted between the two scales. Raters' experience did not affect the scales' predictive value. Both scales showed excellent accuracy in identifying comatose patients (AUCs > 0.950). The difference between admission and discharge values was not a reliable predictor.

CONCLUSION

Both the FOUR Score and GCS are reliable predictors of short- and long-term outcome, with no clear superiority among them. The application of the FOUR Score by inexperienced raters is equally reliable, without influencing negatively the predictive value.

Clinimetric study and review of the Reaction Level Scale

OBJECTIVES

Although the Reaction Level Scale (RLS) is still used for the assessment of the level of consciousness in distinct centers, its clinical characteristics and significance have been incompletely researched. In the current study, the clinimetric properties, the prognostic value, and the impact of the raters' background on the application of the RLS, in comparison with the Glasgow Coma Scale (GCS), are investigated.

MATERIALS AND METHODS

A systematic review on the available clinical evidence for the RLS was first carried out. Next, the RLS was translated into Greek, and patients with neurosurgical pathologies in need of consciousness monitoring were independently assessed with both RLS and GCS, by four raters (two consultants, one resident, and one nurse) within one hour. Interrater reliability, construct validity, and predictive value (mortality and poor outcome, at discharge and at 6 months) were evaluated.

RESULTS

Literature review retrieved 9 clinimetric studies related to the RLS, most of low quality, indicating that the scale has not been thoroughly studied. Both versions of the RLS (original and modified) showed high interrater reliability (κ_w >0.80 for all pairs of raters), construct validity (Spearman's p > .90 for all raters), and prognostic value (areas under the curve >0.85 for all raters and outcomes). However, except for broader patients' coverage, it failed to show any advantage over the GCS.

CONCLUSIONS

The RLS has not succeeded in showing any advantage over the GCS in terms of reliability and validity. Available evidence cannot justify its use in clinical practice as a substitute to the widely applied GCS.

Comparison of the Full Outline of Unresponsiveness Score with the Glasgow Coma Scale as a Coma Assessment Scale in Pediatric Intensive Care

Rapid assessment of cerebral dysfunction is crucial for the management of patients in intensive care units. The Glasgow Coma Scale (GCS) evaluates eye, verbal, and motor responses, but is insufficient to effectively evaluate patients on mechanical ventilation, or who are unable to speak. The Full Outline of Unresponsiveness (FOUR) score includes additional information such as brainstem reflexes and respiratory status to provide a more complete clinical assessment. In this study, we aimed to compare the FOUR score with GCS in the assessment of patients with coma. This prospective study included patients between 1 month and under 18 years of age, who were hospitalized in the pediatric intensive care unit due to risk of coma or ongoing impairment of consciousness between May 2018 and June 2019. Information regarding FOUR scores, GCS values, patient demographics, duration of hospitalization, requirement for mechanical ventilation, and patient comorbidities were recorded and analyzed. Among the 80 patients included in the study, a statistically significant correlation was found between (low) GCS and FOUR scores during admission, and mortality and requirement for mechanical ventilation. Monitoring the level of consciousness is important in pediatric intensive care units and may be predictive of the course and disease outcome. Similar to the GCS, the FOUR score is a good indicator for predicting mortality and requirement for mechanical ventilation.

Cross-Cultural Adaptation and Validation of the Greek Version of the "Full Outline of Unresponsiveness Score": A Prospective Observational Clinimetric Study in Neurosurgical Patients

Background

The Full Outline of Unresponsiveness (FOUR) score is a clinical instrument for the assessment of consciousness which is gradually gaining ground in clinical practice, as it incorporates more complete neurological information than the Glasgow Coma Scale (GCS). The main objectives of the current study were the following: (1) translate and cross-culturally adapt the FOUR score into Greek; (2) evaluate its clinimetric properties, including interrater reliability, internal consistency, and construct validity; and (3) evaluate the reliability of assessments among health care professionals with different levels of experience and training.

Methods

The FOUR score was initially translated into Greek. Next, patients with neurosurgical pathologies in need of consciousness monitoring were independently assessed with the GCS and FOUR score within one hour by four raters who had different levels of experience and training (two board-certified neurosurgeons, a neurosurgery resident, and a registered nurse). Interrater reliability, internal consistency, and construct validity were evaluated for the scales using weighted Cohen’s κ (κ_w) and intraclass correlation coefficients (ICC), Cronbach’s α and Spearman’s ρ values, respectively.

Results

A total of 408 assessments were performed for 99 patients. The interrater reliability was excellent for both the FOUR score (ICC = 0.941) and GCS (ICC = 0.936). The values of κ_w exceeded 0.90 for all pairs, suggesting that the FOUR score can be reliably applied by raters with varying experience. Among the scales’ components, FOUR score’s brainstem and respiratory items showed the lowest, yet high enough (κ_w > 0.60), level of agreement. The interrater reliability remained excellent (κ_w > 0.85, ICC > 0.90) for all diagnosis and age groups, with a trend toward higher FOUR score values in the most severe cases (ICC = 0.813 vs. 0.723). Both the FOUR score and GCS showed high internal consistency (Cronbach’s α > 0.70 for all occasions). The FOUR score correlated strongly with GCS (Spearman’s ρ > 0.90 for all raters), suggesting high construct validity.

Conclusions

The Greek version of the FOUR score is a valid and reliable tool for the clinical assessment of patients with disorders of consciousness. It can be applied successfully by nurses, residents, and specialized physicians. Therefore, its use by medical practitioners with different levels of experience and training is strongly encouraged.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12028-021-01342-w.

A Novel INCNS Score for Prediction of Mortality and Functional Outcome of Comatose Patients

Objectives: The purpose of this study was to verify the veracity and reliability of the INCNS score for prediction of neurological ICU (NICU) mortality and 3-month functional outcome and mortality in comatose patients.

Methods: In this prospective study, data of the patients admitted to NICU from January 2013 to January 2019 were collected for validation. The 3-month functional outcomes were evaluated using modified Rankin Scale (mRS). By using the receiver operating characteristics curve (ROC) analysis, we compared the INCNS score with Glasgow Coma Scale (GCS), Full Outline of Un-Responsiveness Score (FOUR) and Acute Physiology and Chronic Health Evaluation II (APACHE II) for assessment of the predictive performance of these scales for 3-month functional outcome and mortality and NICU mortality performed at 24- and 72-h after admission to the NICU.

Results: Totally 271 patients were used for evaluation; the INCNS score achieved an AUC (area under the receiver operating characteristic curve) of 0.766 (95% CI: 0.711–0.815) and 0.824 (95% CI: 0.774–0.868) for unfavorable functional outcomes, an AUC of 0.848 (95% CI: 0.800–0.889) and 0.892 (95% CI: 0.848–0.926) for NICU mortality, and an AUC of 0.811 (95% CI: 0.760–0.856) and 0.832 (95% CI: 0.782–0.874) for the 3-month mortality after discharge from the NICU at 24- and 72-h. The INCNS score exhibited a significantly better predictive performance of mortality and 3-month functional outcomes than FOUR and GCS. There was no significant difference in predicting NICU mortality and 3-month functional outcomes between INCNS and APACHE II, but INCNS had better predictive performance of 3-month mortality than APACHE II.

Conclusions: The INCNS score could be used for predicting the functional outcomes and mortality rate of comatose patients.

Update on diagnosis in disorders of consciousness

INTRODUCTION

New guidelines regarding the diagnosis of disorders of consciousness (DOC) (such as vegetative state and minimally conscious state) have recently been published by the American Academy of Neurology and the European Academy of Neurology. This follows an impressive number of prospective studies performed on DOC and recent multi-centric studies with larger sample size, which have gathered precious information on the recovery of cohort of patients through years and which now call for a better management of patients with DOC.

AREAS COVERED

This review will discuss recent updates on the clinical entities of DOC, the challenges for an accurate diagnosis and the last developments in diagnostic tools.

EXPERT OPINION

The authors will also discuss the impact of the new guidelines on their way of diagnosing patients and how diagnosis will most likely change in a near future.

Automated pupillometry and the FOUR score - what is the diagnostic benefit in neurointensive care?

Introduction

The Glasgow Coma Scale (GCS) and visual inspection of pupillary function are routine measures to monitor patients with impaired consciousness and predict their outcome in the neurointensive care unit (neuro-ICU). Our aim was to compare more recent measures, i.e. FOUR score and automated pupillometry, to standard monitoring with the GCS and visual inspection of pupils.

Methods

Supervised trained nursing staff examined a consecutive sample of patients admitted to the neuro-ICU of a tertiary referral centre using GCS and FOUR score and assessing pupillary function first by visual inspection and then by automated pupillometry. Clinical outcome was evaluated 6 months after admission using the Glasgow Outcome Scale-Extended.

Results

Fifty-six consecutive patients (median age 63 years) were assessed a total of 234 times. Of the 36 patients with at least one GCS score of 3, 13 had a favourable outcome. All seven patients with at least one FOUR score of ≤ 3 had an unfavourable outcome, which was best predicted by a low “brainstem” sub-score. Compared to automated pupillometry, visual assessment underestimated pupillary diameters (median difference, 0.4 mm; P = 0.006). Automated pupillometry detected a preserved pupillary light reflex in 10 patients, in whom visual inspection had missed pupillary constriction.

Discussion

Training of nursing staff to implement frequent monitoring of patients in the neuro-ICU with FOUR score and automated pupillometry is feasible. Both measures provide additional clinical information compared to the GCS and visual assessment of pupillary function, most importantly a more granular classification of patients with low levels of consciousness by the FOUR score.

Prognostic roles of sleep electroencephalography pattern and circadian rhythm biomarkers in the recovery of consciousness in patients with coma: a prospective cohort study

OBJECTIVE

To investigate the potential prognostic value of sleep electroencephalography (EEG) pattern and serum circadian rhythm biomarkers in the recovery of consciousness in patients at the acute stage of coma.

METHODS

A prospective observational study which included 75 patients with coma was conducted. Twenty-four-hour continuous polysomnography (PSG) was performed to determine the sleep EEG pattern according to the modified Valente's Grade (mVG) that we proposed. Serum levels of melatonin and orexin-A at four consecutive time points during the PSG were examined. Patients were then followed for one month to determine their level of consciousness. Multivariate logistic regression analysis was performed to examine associations between demographics, aetiology, baseline clinical features (pupillary and corneal reflex, and neuron-specific enolase [NSE]), clinical scores (Glasgow Coma Scale-Motor Response [GCS-M], Full Outline of Unresponsiveness [FOUR] scale, Acute Physiology and Chronic Health Evaluation II [APACHE II] scale), mVG, serum circadian biomarkers, and recovery of consciousness within one month.

RESULTS

Within one month of enrolment, 34 patients regained consciousness and 36 patients remained non-conscious. Spearman rank correlation revealed a significant association between mVG and state of consciousness after one month. Significant variation in serum melatonin or orexin-A was not detected in either the conscious or non-conscious groups. Hypoxic aetiology, APACHE II, and mVG were independently associated with recovery of consciousness within one month.

CONCLUSION

Sleep EEG structure, hypoxic aetiology, and APACHE II can independently predict recovery of consciousness in patients with acute coma. Taken together, we encourage neurologists to use sleep elements to assess patients with acute coma.